- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,510.05 / $4,731.71 / $5,006.87
| Professional | | $3,510.05 | $4,731.71 | $5,006.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $511.89 / $602.22 / $602.22
| Professional | | $511.89 | $602.22 | $602.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,608.68 / $7,608.68 / $7,608.68
| Facility | | $7,608.68 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,467.38 / $7,608.68 / $7,608.68
| Professional | | $6,467.38 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,496.07 / $4,359.24 / $6,313.73
| Professional | | $2,496.07 | $4,359.24 | $6,313.73 |